Provider Demographics
NPI:1619069762
Name:RISK, JESSICA (MPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RISK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-0841
Mailing Address - Country:US
Mailing Address - Phone:818-599-6049
Mailing Address - Fax:310-919-3600
Practice Address - Street 1:28990 PACIFIC COAST HWY BLDG A
Practice Address - Street 2:SUITE 205-C
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-3952
Practice Address - Country:US
Practice Address - Phone:818-599-6049
Practice Address - Fax:310-919-3600
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP74713Medicare UPIN
CAP74713Medicare UPIN